Healthcare Provider Details

I. General information

NPI: 1245609239
Provider Name (Legal Business Name): JESSICA WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2015
Last Update Date: 09/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 OLD HOLZWARTH RD APT 1705
SPRING TX
77388-4797
US

IV. Provider business mailing address

2111 OLD HOLZWARTH RD APT 1705
SPRING TX
77388-4797
US

V. Phone/Fax

Practice location:
  • Phone: 832-996-1171
  • Fax:
Mailing address:
  • Phone: 832-996-1171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number170552
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number170552
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: